Parent’s Perceptions about the Cause of their Child’s Mental Health Problem:
Development of a Parent Report Measure
Center of Excellence for Child and Youth Mental Health at CHEO: Final Report
February 6, 2008
Graham J. Reid, Ph.D.
(Principal Investigator)
Departments of Psychology and Family Medicine
The University of Western Ontario
London, Ontario
Dianne Shanley, M.A.
(Co-Principal Investigator)
Department of Psychology
The University of Western Ontario
London, Ontario
Rick Goffin, Ph.D.
Department of Psychology
The University of Western Ontario
London, Ontario
Judith Belle Brown, Ph.D.
Departments of Family Medicine and Paediatrics,
Schulich School of Medicine and Dentistry
The University of Western Ontario
London, Ontario
Barrie Evans, Ph.D.
Madame Vanier Children’s Services
London, Ontario
Shannon L. Stewart, Ph.D.
Child and Parent Resource Institute
London, Ontario
Vicky Wolfe, Ph.D.
Child and Adolescent Centre
London Health Sciences Centre
London, Ontairo
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Dianne Shanley is now at the School of Behavioral and Cognitive Social Sciences, The
University of New England, Australia
Dr. V. Wolfe is now at the IWK-Grace Health Centre, Halifax, Nova Scotia
Corresponding authors:
Graham J. Reid, Ph.D., C.Psych.
Associate Professor
Psychology & Family Medicine
Westminster College, Room 319E
The University of Western Ontario
361 Windermere Road
London ON N6A 3K7
Phone: (519) 661-2111 x84677
Fax: (519) 661-3340
Email: [email protected]
Dianne Shanley, M.A.
Psychology
University of New England
Armidale, NSW 2351
Australia
Phone: (02) 6773 2527
Fax: (02) 6773 3820
Email: [email protected]
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EXECUTIVE SUMMARY
Background
About one out of every five children and adolescents with mental health problems received
treatment. We recently found that about 8-25% of parents seeking help for their child
philosophically disagreed with a treatment they had been offered. Disagreement with treatment
approaches could result in treatment dropout or decreased treatment compliance. Current dropout rates range from 28-75%. This decreases positive treatment outcomes and increases costs to
mental health services, which are already under funded. One factor that may impact parents’
agreement with treatment is how they perceive their child’s mental health problem, specifically,
their perception of what caused their child’s problem(s). The field of developmental
psychopathology has shown that multiple developmental and contextual factors interacting over
time leading to mental health problems. In contrast, parents often view their child’s problem
(e.g., aggressive behavior) as resulting from a single, contextual factor (e.g., divorce). Parents
with this perception may have prescribed views about what types of treatment their child should
receive (e.g., anger management). Such fixed views on treatment could lead to inflexibility when
options for treatment are presented to the parent. These parents may be more likely to drop out of
treatment if the treatment offered does not match their perception of what caused the problem.
We conducted two studies related to parents’ perceptions of their children’s mental health
problems. In the first study, parents were interviewed about their perceptions. In the second
study, a questionnaire measuring parent perceptions was developed and tested.
Objectives
1. To describe parents’ perceptions about the cause and development of their child’s mental
health problems (Study 1).
2. To create a valid and reliable scale measuring parents’ perceptions about the cause of their
child’s problem (Study 2).
Methods
Study 1. Parents seeking help at one of three Children’s Mental Health Centres (N=25) for a
child age 5 to 12 were interviewed. Open-ended questions asked about parents’ perception of the
cause and development of their child’s problem.
Study 2. A scale measuring parents’ perceptions about the cause of their child’s mental
health problem was developed. Twelve mutually exclusive, specific dimensions of perceptions
about cause were created from the qualitative themes that emerged in Study 1, and from basic
premises of developmental psychopathology. Six researchers/clinicians evaluated the clarity and
content validity of the initial 143 items . The 108 items retained following the expert ratings
were administered to 387 parents seeking help from one of five Children’s Mental Health
Centres for their child aged 5- to 12-years-old. Item reduction strategies were employed resulting
in a 60-item scale. Confirmatory factor analysis tested the proposed factor structure and
convergent and discriminant validity, and internal consistency were examined.
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Summary of Main Findings
Study 1.
There was wide variation in the complexity of parents’ perceptions about child mental
health problems. Although there were parents who endorsed simple causal models, others
perceived the cause of their child’s mental health problem more complexly. Parents perceived a
variety of different causes covering multiple domains (i.e., child, parent, family, community) as
responsible for their child’s mental health problem. Four patterns emerged to describe how
parents were able to integrate the presence of multiple causes, including linear, equifinality,
cumulative and complex patterns. The results demonstrated that current measures evaluating
cause do not sufficiently explore the breadth and complexity of the causes perceived by parents.
Study 2.
Confirmatory factor analysis demonstrated that the proposed 12 factor model was a fair and
reasonable fit to the data. All items from the Cause Questionnaire meaningfully contributed to
their intended subscale demonstrating construct validity. The hypothesized theoretical
relationships with previously established measures demonstrated convergent validity. For
example, the more parents perceived medication as acceptable, the more they viewed biology as
a cause (r = .44).
The complexity of parents’ perceptions about child mental health problems was
significantly related to the severity of the problem (r = .44) and the number of treatments
received for the child’s problem (r = .19).
General complexity of thought about life issues was not significantly related endorsing
multiple causes (r = .01), which indicates that endorsing multiple causes was not a function of
“thinking complexly” but rather a function of understanding childhood psychopathology.The
lack of a relationship with theoretically dissimilar measures, such as the aesthetic appreciation
subscale and self-deceptive enhancement subscales demonstrated discriminant validity.
The average parent perceived five causal categories as responsible for their child’s mental
health problem, demonstrating that parents tend to have a multi-dimensional view about the
cause of their child’s problem. Although some parents endorsed a simple causal model (4%
endorsed only 1 of the 12 factors as causing their child’s problems), the majority perceived
multiple factors as causing their child’s problem.
Summary of Clinical Implications
Parents’ perceptions of cause were related to the acceptability of common treatment
options, demonstrating that parents’ perceptions about the cause of their child’s mental health
problem can inform our understanding of which treatments parents view as acceptable.
Practitioners who attend to parents’ perceptions can have the option of either matching the
treatment regimen to parents’ perceptions or altering parents’ perceptions to match the
requirements of the treatment. Such patient-centred approaches can enhance the therapeutic
alliance, which has been demonstrated to improve treatment outcome
Summary of Research Recommendations
The results demonstrated that the current methods of measuring cause do not capture the
breadth of causes that parents perceive. Our new measure is the only questionnaire that allows
for the exploration of multiple causes within parents’ perceptions and it provides a solid
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foundation for future research to examine the influence of cause on the treatment process.Future
research could (a) test if subgroups of parents share particular views about cause (i.e., parents
with no previous treatment, parents of children with more severe problems, parents of children
with different types of problems), (b) how differing perceptions of cause influence the treatment
process (i.e., problem recognition, help-seeking, treatment acceptance, and treatment
engagement), and (c) test if the discrepancy between parents’ perceptions of cause differ and
clinician’s perceptions influences the treatment process.
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Introduction and Background
Parents have differing perspectives about what causes their child’s problem and how such
problems develop over time. Understanding parents’ perceptions can inform the treatment
process. For example, parents’ perceptions have the potential to influence their recognition of the
problem, their help-seeking behaviour, and their engagement and adherence with treatment
(Kerkorian, McKay, & Bannon, Jr., 2006; Morrissey-Kane & Prinz, 1999; Greenberg,
Constantino, & Bruce, 2006; Nock & Photos, 2006). More specifically, perceptions about what
caused a child’s problem could influence a parent’s decisions about the type of treatment that
s/he feels is most appropriate. Imagine a parent who views their child’s depression as being
caused by bullying, and as a result, thinks that a class in assertiveness skills would be the best
treatment for the child and seeks help from a centre that provides mental health care for children.
The centre offers the parent a parenting class as part of the larger treatment plan for the child.
The parent, however, does not understand how or why a parenting class would help their child
become more assertive, so they either do not attend the class, or they attend, but do not apply the
information taught in the class. This scenario is familiar to many clinicians, but there is a
relatively limited amount of research examining how parents’ perceptions about the cause of
their child’s mental health problem can influence the treatment process (Shanley & Reid, 2008b).
The Self-Regulation Model (SRM) by Leventhal et al. (1980; 1984; 1998) provides one way
of understanding parent’s perceptions of their child’s mental health problem (Shanley et al.,
2008b; Lobban, Barrowclough, & Jones, 2003). The SRM defines illness representations as the
way in which people make sense of their experience with an illness. These representations guide
coping responses (Weinman & Petrie, 1997). When applied to a parent’s perceptions of their
child’s mental health problem, nine dimensions are relevant: identity, cause, timeline
(acute/chronic), timeline (cyclical), personal control, treatment control, consequences, illness
coherence, emotional representations (Weinman, Petrie, Moss-Morris, & Horne, 1996; MossMorris et al., 2002). Eight of the nine dimensions are able to be measured using previously
established or adapted questionnaires. Identity (i.e., the symptoms associated with the illness)
can be measured using symptom questionnaires such as the Child Behaviour Checklist
(Achenbach, 1991). With the exception of cause, the remaining dimensions can be measured by
adapting the Revised Illness Perception Questionnaire, the most widely validated and used tool
for measuring peoples’ perceptions of health problems (Moss-Morris et al., 2002; Shanley et al.,
2008b). There is not, however, a currently validated measure for examining parents’ perceptions
of cause. Until we can reliably and validly measure parents’ perceptions of cause, there is a gap
in our ability to study parent representations of their child’s mental health problems. We
conducted two studies related to parents’ perceptions of their children’s mental health problems.
In the first study, parents were interviewed about their perceptions. In the second study, a
questionnaire measuring parent perceptions was developed and tested.
Objectives
1. To describe parents’ perceptions about the cause and development of their child’s mental
health problems (Study 1).
2. To create a valid and reliable scale measuring parents’ perceptions about the cause of their
child’s problem (Study 2).
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STUDY 1: A Qualitative Examination of Parents’ Perceptions of Cause
Review of Related Research
Professionals have a fairly clear understanding about the cause, development and
maintenance of children’s mental health problems. We know from previous research in
developmental psychopathology that: 1) children’s mental health problems result from the
interaction between multiple biological, psychological and social processes that act as risk and
protective factors (Shirk, Talmi, & Olds, 2000). 2) “There are multiple pathways to one disorder
(equifinality) and one pathway may have multiple outcomes (multifinality)” (Hudson, Kendall,
Coles, Robin, & Webb, 2002), p.821). 3) The accumulation of risk and protective factors over
time leads to the development of psychopathology. Exposure to risk factors during critical
periods increases the likelihood of developing psychopathology, but the perpetuation of
psychopathology depends upon exposure to subsequent risk and protective factors (Shirk et al.,
2000). 4) Risk and protective factors can be nonlinear, bi-directional, or reciprocal. The child
and his environment are not mutually exclusive; they are constantly interacting and altering each
other based on previous exchanges (Shirk et al., 2000; Kazdin, Kraemer, Kessler, Kupfer, &
Offord, 1997).
It is unclear whether parents share this complex understanding of the cause, development
and maintenance of children’s mental health problems. Research suggests parents are more likely
to endorse either a disease model or a simple causal model when conceptualizing child mental
health problems. A disease model, which first originated in medicine, describes maladaptive
functioning as a syndrome that is either present or absent (Shirk et al., 2000; Sroufe, 1997). For
example, a parent who views their child’s depression as either present or absent would likely
endorse the disease model, negating the notion that mental health problems exist on a continuum
of severity. Johnston and Freeman (1997) provide an example of parents who likely endorse the
disease model. In a sample of 54 parents of children with Attention Deficit Hyperactivity
Disorder (ADHD), the majority described an incident of their child’s behavior as an enduring
symptom of an underlying neurological disorder. If the disorder had not been present, their child
would not have been displaying the symptoms, thus implying that they viewed ADHD as a
disorder that can be categorically present or absent within their child (Johnston & Freeman,
1997).
A simple causal model implies there is only one cause to the child’s problem, and without
that cause, the problem would not exist. For example, just as bacteria causes infection, parents
might believe bullying causes depression. Although no known studies to date have directly
examined whether parents endorse a simple causal model when thinking about their child’s
mental health problem, attributional research has shown that parents are more likely to believe
there is a primary cause for their child’s problematic behavior (Morrissey-Kane et al., 1999;
Baden & Howe, 1992; Bradley & Peters, 1991; Compas, Adelman, Freundl, Nelson, & Taylor,
1982). Johnston and Freeman (1997) examined parental attributions about the cause of
inattentive behavior and found that parents with ADHD children viewed a neurological disorder
as the primary cause of their child’s inattention. They did not view the cause as involving other
characteristics such as parenting skills or child temperament; therefore negating developmental
psychopathology’s stance that a number of risk factors can lead to the development of a disorder.
Other studies examining parents of children with oppositional defiance or conduct disorder found
that when recalling an incident of their child’s misbehavior, parents placed the onus of the
child’s problem on the child, viewing the problem as a function of dispositional factors within
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the child and minimizing their parental role in the development of the disorder (Compas et al.,
1982; Bradley et al., 1991; Morrissey-Kane et al., 1999; Baden et al., 1992). This implies that
these parents consider the child’s disposition to be the primary (but not necessarily the only)
cause for their child’s behavioral or emotional problems. There has only been one recent study
examining the variety of different causal factors parents perceive to be responsible for a variety
of child mental health problems (Yeh, Hough, McCabe, Lau, & Garland, 2004a). Yeh et al.
(2004) examined ethnic differences in how parents explain their child’s mental health problems.
Parents of 1,338 youths with mental health problems were asked about what they believed to be
the causes of their child’s problems. The interviewer-administered questionnaire contained
eleven causal categories, reduced into three global causal categories: biopsychosocial (e.g.,
personality, family issues), sociological (e.g., friends, culture) and spiritual/nature disharmony
(e.g., possession, disruption of energy). Significant differences in beliefs between ethnic groups
were found. However, the percentage of parents who endorsed single or multiple causes was not
reported.
Attributions about behavior are unique from perceptions of mental health problems. An
attribution is an explanation, understanding or prediction of an event or behavior based upon
cognitive perception (Antaki & Brewin, 1982; Försterling, 1988; Hewstone, 1989). Therefore,
the focus of attribution research is placed on explaining a single behavior and the results of these
studies could be due to the method of assessment rather than parents’ views. It is quite probable
that a single, isolated behavior would have only one cause. Conversely, if parents were asked
about a syndrome of related behaviors (such as a mental health problem) rather than specific
behaviors, they might view a syndrome as having multiple causal factors. The need to examine
and understand multiple causes increases when we examine patterns of behavior, such as mental
health problems.
In addition to understanding what parents’ perceive to be the cause of mental health
problems or patterns of behavior, there is a need to study parents’ perception of how the problem
developed over time. At present, we do not have a clear understanding of how parents’ perceive
the cause and the development of their child’s mental health problem. The objective of this study
was to describe how parents view the cause and the development of their child’s mental health
problem using a qualitative research design. Given the lack of research on this topic, the
exploratory and descriptive strengths of the qualitative method can describe parent perceptions
with the breadth, depth, and clarity that is necessary at this preliminary stage of research.
Methodology
The phenomenological approach was the qualitative research strategy used to explore the
research question (Crabtree & Miller, 1999). This approach was chosen because it allows
researchers to reflectively set aside their preconceived notions the topic of study, in this case
child mental health problems, and to best understand the lived experience of participants; for our
study, these were parents who are raising a child with a mental health problem).
Recruitment
Parents seeking help for their child’s behavioral or emotional problems were recruited
from one of three Children’s Mental Health Centres in London, Ontario (population 337,000,
metropolitan area 432,000). The study was limited to children age 5-12 years old, as this is the
age range when many mental health problems first occur and where parents play a central role in
the treatment of children. Two procedures for recruitment were used at each CMHC: 1) Intake
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workers asked parents if they were willing to be contacted about the study and forwarded the
contact information of parents who agreed to research staff. 2) Receptionists at each agency
provided a handout inquiring about the possibility of being contacted for a research project to
parents arriving for an appointment. Interested parents provided their contact information on the
handout to receptionists, who then forwarded the information to research staff.
Research staff mailed a letter of information to parents and obtained informed consent by
telephone. Parents who agreed to participate arranged a meeting with the research assistant for
an interview at the CMHC from which they were seeking help. Interviews were conducted in a
private room at each Centre. Parents who could not arrange an in-person interview completed
the interview over the telephone.
The study was approved by the University of Western Ontario’s Institutional Review
Board. Participants received a $20 gift certificate for completing the interview.
Data Collection
The semi-structured interview administered to parents consisted of open-ended questions
asking parents to describe: (a) the type of problem their child has experienced; (b) what caused
the problem; (c) how it developed over time; (d) what maintained the problem (or caused it to
continue); and (e) what would make the problem better. All interviews were recorded and
transcribed verbatim. Data analyses were conducted concurrently as interviews were completed.
Interviews continued until the researchers had a good understanding of participants’ perceptions
and when theme saturation occurred (Patton, 2002).
Data Analyses.
Two researchers independently reviewed the transcripts to identify key concepts and
emerging themes. Researchers then met to compare and corroborate their findings. Discrepancies
between the two researchers were discussed and resolved as needed. Quotes and transcripts were
presented to a third researcher who corroborated the key concepts and themes. Analyses were
supported by the use of NVivo (QSR International, 2007), a computer program that helps to
organize individual quotes into key concepts and themes (see Table 1).
The analyses utilized the strategies outlined by Crabree and Miller (1999) of
crystallization and immersion to identify overarching themes within the data. In this method,
researchers immersed themselves in the transcripts and reflected on the experiences of
participants. These reflections guided the themes and patterns that emerged across participants.
Patterns transpired from diagrams created in response to each parent’s story. The diagrams
outlined the causes perceived by each parent and the themes relevant to each parent.
Independent researchers evaluated the credibility of each diagram by returning to the transcript
in an attempt to disconfirm the diagram.
Trustworthiness and Credibility.
Trustworthiness and credibility were ensured by conducting independent and team
analyses, which provided investigator triangulation (Guion, 2002). All researchers were trained
by a qualitative expert. Researchers were from multiple disciplines, including social work,
family medicine and psychology, providing theory triangulation (Guion, 2002). Researchers
searched for negative cases that would disconfirm emerging themes.
Final Sample.
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Forty-eight parents allowed the intake staff at the CMHC’s to forward their contact
information to the research team. Once contacted by the research team, 24 parents agreed to
participate, eight declined, and 16 could not be contacted despite multiple attempts. The 24
participating parents reflected maximum variation based on child and parent age, child and
parent gender, rural/urban living situations, and child problem type and severity. The 24
participating parents were an average of 35 years old, ranging from age 25 to 46; there were 21
mothers, 1 father and 2 legal guardian grandmothers. Children of participating parents were an
average of 9 years old ranging from age 6 to 12; 18 were male. Eight of the families lived in a
rural location. All families were actively seeking help from a children’s mental health agency.
Based on parents’ description of the problem, children had a range of both externalizing and
internalizing problems. Externalizing problems included problems such as attention deficit
hyperactivity disorder, oppositional defiant disorder, Tourettes disorder, bipolar disorder, anger
and aggression problems. Internalizing problems included depression, and anxiety (generalized
worry, phobias, separation anxiety and obsessive compulsive disorder).
Results
Overarching Themes.
One overarching theme permeated all aspects of parents’ perceptions about their child’s
mental health problem was the theme of complexity. The complexity of perceptions about the
cause of child mental health problems was varied. Some parents had a very uncomplicated,
straightforward, and sometimes inflexible view of the problem. When asked about what caused
her child’s anger problems to continue, one parent stated, “I think it has to do with his Tourette’s.
I think it’s as plain and simple as that. Once the Tourette’s has vanished, he’ll be fine.”
Some parents were in the process of conceptualizing their child’s problem, hence their
perception about what caused the problem was somewhat ill defined. They appeared to be
considering different causes and options for treatments as they spoke with the researcher. When
asked about what caused her child’s problems to continue, one parent stated,
“I really don’t know, to be quite honest, I really don’t know whether it’s how we say
things to him, what we say to him; whether it’s our approach to parenting or whether it’s
the way he internalizes the dialogue. I don’t know.”
Some parents demonstrated a very complex, multifaceted understanding of the cause and
development of their child’s mental health problem. As one parent stated,
“I think that the genetics and the negative life experiences have fuelled both [her bi-polar
and her ADHD]. Any emotional distress would have a negative impact on either disorder
… I think that the diagnostics are correct. It has to be a combination of we haven’t quite
hit the right medication or the correct dose and also my inability or lack of knowledge of
how to deal with a child that’s bi-polar.”
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The multitude of causes.
Parents reported a variety of causes for their child’s problem crossing multiple domains.
The breadth of causes described across parents is summarized by themes and sub-themes in
Table 1. Theme saturation was met, in that all examples of causes provided by parents fell into
one of the themes. To help conceptualize the multitude of themes and sub-themes, themes were
organized into broader domains.
The ability to integrate multiple causes.
Four patterns describing how parents integrated the presence of multiple causes emerged
from the analyses (See Figure 1). These patterns should be viewed as isolated ‘snap-shots’
representing parents’ perceptions of what was currently causing their child’s mental health
problem (i.e., at the time of the interview). The patterns were: (1) Linear, (2) Equifinality, (3)
Cumulative, (4) Complex. To provide an example, one pattern will be described below and
accompanied by an example from one parent. For further examples, see Shanley, Brown, Reid,
& Paquette-Warren (2008a).
The cumulative model represented how some parents described their child’s problem as
being caused by multiple factors, where each cause was unrelated to the other causes, but the
causes followed a chronological sequence, whereby over time, each cause added to the previous
cause, progressively making the problem worse. The cumulative model is different from linear
model in that each progressive cause was not a direct result of the previous cause. For example, a
parent might have stated that her child was bullied at school, and then a close grandparent died,
after which they moved to a new neighbourhood, separating him from his only friend. Each
event was unrelated to previous event; however, the cumulative effect of each event resulted in
the mental health problem. This model is different from the equifinality model because each new
cause multiplied the effect of previous causes. One parent used the word “snowballing” to
describe how the causes had accumulated over time to result in the problem.
For example, the mother of a nine-year-old boy who was defiant and aggressive at school
described her child’s problem as starting because he didn’t have
“any other siblings around. He never went to preschool, he never went to daycare. Just
really never had any kids around to play with and all a sudden he went to school and
there’s 27 kids in his class and 300 kids out in the playground and he just didn’t know
what to do … he didn’t really know how to deal with socializing with a group of kids.”
She continued to explain how she had separated from his father when he was seven, shortly after
school had started, and how, since the separation, there had been “two sets of parenting rules and
that was a big issue.” She was clear that the separation had added to the stress of attending
school, “The problems at school have escalated since [the separation]”. She also added that after
the separation “he had a lot of people pass away that he’s known … like his great grandmother,
his aunt, a fellow that lived beside us that he knew since he was born, his dog, two of his
rabbits”, which exacerbated the problem.
The mother clearly perceived the chain of events that caused her child’s problem as
cumulative, whereby each event added to or “snowballed” on previous events. This parent did
not fall into the linear category because starting school was unrelated to parental separation,
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which was unrelated to deaths in the family. For a more elaborate explanation of themes, causes
and patterns that emerged see Shanley, Brown, Reid, & Paquette-Warren (2008a).
Conclusions and Recommendations
There was wide variation in the complexity of parents’ perceptions about child mental
health problems. There were parents who endorsed simple causal models, but some parents were
quite capable of perceiving the cause of their child’s mental health problem more complexly.
Parents in this study demonstrated a much broader range of responses about their perceptions of
cause than current questionnaires evaluating parents’ perceptions about the cause of child mental
health problems allow (Yeh et al., 2004a; Angold, Costello, Burns, Erkanli, & Farmer, 2000).
Indeed, current questionnaires do not include items from each of the content areas outlined in this
study (Table 1). This suggests that current measures are not sufficient to accurately reflect the
diversity of parents’ perceptions. Given the breadth of potential causes that parents can perceive,
it would be beneficial to create a more comprehensive measure of parents’ perceptions about the
cause of child mental health problems.
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STUDY 2 - Parents’ Perceptions of Cause: Development of a Parent-Report
Measure
Review of Related Research
Three studies have previously examined parents’ perceptions about cause. Yeh, Hough,
McCabe, Lau, and Garland (2004b) examined ethnic differences around how parents explain
youth problems. Parents of 1,338 youths who had mental health problems were asked about
what they believed to be the cause of their child’s problems. They administered a structured
interview asking parents to endorse 11 causal categories (i.e., yes/no), that were reduced into
three global categories: biopsychosocial (e.g., personality, family issues), sociological (e.g.,
friends, culture) and spiritual/nature disharmony causes (e.g., possession, disruption of energy).
There are a few methodological issues with this approach. First, forcing dichotomous responses
may have limited parents’ endorsement of some categories. Parents who were uncertain if, for
example, the negative influence of peers was a cause of their child’s problem may have tended
to endorse “no”, and thus underestimate the complexity of their causal perceptions. Second, the
11 categories contained two to 10 dichotomous items. If at least one of the items within a
causal category was endorsed, the category was considered endorsed. Rather than factor
analyzing the items, which would provide construct validity for each factor, the authors’ factor
analyzed the dichotomous causal categories. As a result, statistically, there was no assurance
that the items validly reflected the category to which they were assigned. Third, the measure
was designed to assess ethnicity differences in perception. As such, one of the three factors was
spiritual/nature disharmony causes, presumably because the authors felt that this dimension
would be one on which various ethnic groups would have quite disparate views. It is unclear
whether this category would reflect the underlying views of causality across parents in general.
Finally, interview measures are time intensive to administer.
Parents’ perceptions about cause also have been measured as part of a larger study
assessing the impact of child problems on parents and families (Angold et al., 2000). The Child
and Adolescent Impact Assessment (CAIA) included 24 subscales measuring areas where the
child’s problem may have impacted the family (e.g., financial difficulties; relationship problems
with spouses or family members; restrictions on activities). One 13 item subscale examined what
parents perceived to be the cause of their child’s problem. The items were part of a semistructured interview and did not have a standardized response style (i.e., some Likert items and
some dichotomous items). There are no published data on these items and the psychometric
properties of the scale have not been tested.
Finally, the qualitative study just discussed aimed at describing how parents view the
cause and the development of their child’s mental health problem demonstrated that there was far
more diversity in parents’ knowledge and perceptions of cause than these previous two studies
examining cause have suggested (Shanley, Brown, Reid, & Paquette-Warren, 2008a). Although
some parents endorsed a simple causal model (i.e., only one cause for the child’s problem), many
described a more complex and multi-faceted understanding of what caused their child’s problem,
similar to the literature on developmental psychopathology (Cicchetti & Richters, 1997; Lewis,
2000).
Therefore, the objective of the present study was to create a valid and reliable
questionnaire that can measure parents’ perceptions about the cause of their child’s mental health
problem. This questionnaire measured perceptions of cause in two ways: (1) Parents may
endorse certain causes more than others. Thus, 12 causal subscales were hypothesized (see
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below). Parents’ degree of endorsement on each subscale was examined. (2) Parents vary in the
extent to which they view their child’s problems as being caused by one or multiple factors.
Thus, the total number of subscales endorsed by parents was examined to provide a measure of
complexity of parents’ views.
Scale Development
The sequential strategy outlined by Jackson was utilized for the development and
retention of items (Jackson, 1970).
Item generation. Mutually exclusive, specific definitions of 12 dimensions measuring
parents’ perceptions about cause were created from the qualitative themes that emerged in
Shanley et al. (2008a) and from established theoretical frameworks, including attribution theory
(Weiner, 1972; Weiner, 1979), developmental psychopathology (Cicchetti et al., 1997; Lewis,
2000; Achenbach, 1990), and ecological systems theory (Bronfenbrenner, 1989; Bronfenbrenner,
1986). See Table 2 for the definition of each dimension. A total of 143 items were created to
reflect the 12 dimensions by using direct quotes from parents who were interviewed in Shanley
et al. (2008a) (see Table 3) and by adapting items used in previous research to evaluate
perceptions about the causes of mental health problems (Yeh, Hough, McCabe, Lau, & Garland,
2004b; Angold et al., 2000). Enough items were generated to ensure that weak items from each
dimension could eventually be discarded (Allen & Yen, 1979), resulting in a 50-60 item final
questionnaire, with no less than three and no more than six items per dimension. Items were
written to be short and straightforward (i.e., less than a grade six reading level), to describe only
one cause (not multiple causes), to avoid double negatives, and to avoid extreme levels of social
desirability (Spector, 1992; Jackson, 1970).
Content validity. Six child-clinical psychologists were asked to: (1) rate item content by
categorically placing items in one of the 12 dimensions, (2) rate item clarity (1 = not clear at all;
7 = very clear), and (3) provide suggestions for additional items. Unclear items were re-worded
and 35 items were deleted because of poor agreement about content across experts.
Construct validity. Construct validity was tested using confirmatory factor analysis,
which tested the fit of the data to the hypothesized 12-factor structure (see below). Convergent
validity for both methods of measuring parents’ causal perceptions, and discriminant validity
were also tested. The convergent validity for “subscale scores” was established by correlating
each subscale scores with a similar or related measure(s). However, given that the underlying
structure of parents’ perceptions about cause has not been previously defined or measured
(Shanley et al., 2008b), administering questionnaires that would provide convergent validity for
all 12 hypothesized subscales was not possible. For example, there are no previous parent-report
measures examining a parents’ perception that the “other parent” is the cause of their child’s
problem. When a theoretical or logical relationship between the specific cause subscale and
another construct has been suggested in previous literature, a measure evaluating that construct
was administered.
Hypotheses included: (1) the more biology was perceived as the cause of the child’s
problem the more medication would be viewed as an appropriate treatment (Freeman &
Johnston, 2001). (2) The more the child’s motivation was perceived to be the cause, (a) the less
efficacy parents would experience (Cunningham & Boyle, 2002; Johnston, 1996), (b) the less
perceived control they would feel over the child behaviour (Jenson, Green, Singh, Best, & Ellis,
1998; Johnston et al., 1997; Sobol, Ashbourne, Earn, & Cunningham, 1989) and (c) the more the
parent would attribute control to the child (Jenson et al., 1998; Johnston et al., 1997; Sobol et al.,
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1989), (d) the more severe externalizing problems would be for the child (Jenson et al., 1998;
Johnston et al., 1997) and (e) the more individual therapy for the child would be viewed as an
acceptable form of treatment. (3) The more emotion dysregulation was perceived to be the cause,
(a) the more severe internalizing problems would be for the child and (b) the more parents would
perceive individual child therapy as an acceptable treatment (Brown, Deacon, Abramowitz,
Dammann, & Whiteside, 2007). (4) When cognitive problems were perceived to be the cause, (a)
children would be more likely to have problems with school participation and achievement, and
(b) parents would be more likely to view treatment at the child’s school as acceptable. (5) The
more spirituality was perceived as a cause, the more parents would believe in fate/chance
(Campis, Lyman, & Prentice-Dunn, 1986). (6) The more a parent perceived themselves as
causing the problem: (a) the more responsibility they assumed for their child’s behaviour
(Campis et al., 1986), and (b) the more acceptable individual parent therapy would be viewed.
(7) The more parents attributed the cause of the problem to the other parent, the more likely they
would find family therapy (involving the other parent) as an appropriate form of treatment. (8)
The more parents attributed the cause of the problem to the community, (a) the more children
would have problems with school participation and achievement and (b) the more likely the
school would be seen as an appropriate treatment. Table 4 summarizes all predictions.
The convergent validity for “complexity scores” was established by correlating
complexity with measures of previous treatment, severity of problem, and a measure of thinking
complexly about life issues. It was predicted that the more subscales a parent endorsed (i.e., the
more complexly they thought about the cause of their child’s problem), (a) the more treatment
they would have received in the past, (b) the more severe the child’s problem would be, and (c)
the more they would demonstrate complexity of thought about life issues.
Discriminant validity was assessed by correlating the 12 subscales with measures that
should, theoretically, have no relationship with each subscale. The 12 cause subscales were not
expected to correlate with a measure of social desirability or aesthetic responding (see Table 4).
Methodology
Participants.
Participants were recruited from one of five Children’s Mental Health Centres in SouthWest Ontario. These centres specialize in treating behavioral and emotional problems for
children and adolescents up to age 18 in urban and rural populations. Each centre is publicly
funded and families seeking treatment do not require a referral to obtain services from the
agency.
Inclusion criteria were: (a) Parents or legal guardians contacting the centre regarding help
for their child, (b) children currently in elementary school (from Junior Kindergarten to Grade 8).
Exclusion criteria were: (a) parents unable to speak or read English, (b) doctors or other
health/mental health care professionals contacting the centre for the parent, (c) parents who were
not the custodial guardian of the child, and (d) children with developmental disabilities.
Participants received a $25 gift certificate from their choice of four stores/restaurants. The study
was approved by the University of Western Ontario’s Ethics Review Board.
Of 4,914 individuals calling the children’s mental health centres during the study period,
3,402 were not eligible and 429 were not asked about the study, leaving 1,083 eligible parents.
Of the eligible parents, 784 agreed to have their contact information provided to the research
team and 769 were contacted; the remainder (n = 15) were unable to be contacted because of a
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wrong telephone number or no answer after repeated attempts. Of the parents contacted, 711
agreed to participate (the primary reason for declining was lack of interest or time) and 487
returned completed questionnaires.
Procedures.
Intake workers asked eligible parents who were seeking help for their child’s behavioral
or emotional problems if they were willing to be contacted about participating in a research study
on “how parents think about their child’s mental health problem”. The contact information of
parents who agreed was forwarded to research staff. Research staff telephoned the parent to
obtain informed consent and parents who agreed were mailed a questionnaire package.
Suggested procedures for increasing the return of mail-out surveys were followed (Dillman,
2007; Edwards et al., 2002). Specifically, a reminder card was sent to parents two weeks post
mail-out. If questionnaires were outstanding at six weeks post-mail-out, a reminder phone call
was made. At eight weeks post-mail-out, a letter was sent stating that our research staff would no
longer be contacting them, but they were welcome to still return the questionnaire if they chose.
Measures.
Descriptive measures
Demographics. Parents reported their age, relationship to the child, family income and
educational attainment.
The Main Problem Questionnaire was created for the purpose of this study. Children
often have multiple co-morbid problems. Rather than limiting the sample to children with only
one problem, which would significantly reduce the ecological validity of our results, we asked
parents to think about their child’s main problem when answering the questionnaire package, as
previous studies has demonstrated that parents tend to seek help for an average of three different
mental health problems (Shanley, Reid, & Evans, 2008c) Parents were asked to choose one of
five main problem categories: (1) attention, concentration, or impulsivity; (2) behaviour or
conduct; (3) mood; (4) social problems; (5) other. Categories were intended to prevent parents
from thinking about one specific symptom (i.e., “he steals”) when answering the questionnaire.
A similar approach has been used in other studies (Battle et al., 1966; Weiss, Catron, Harris, &
Phung, 1999; Weiss, Catron, & Harris, 2000). The content and clarity of these items were tested
in a pilot sample of 17 parents.
Cause Questionnaire
The cause questionnaire administered to parents included 108 items asking about the
cause of their child’s mental health problem. Item generation was described above. All items
started with the common prompt, “My child has this problem because…” and parents rated each
item on a Likert scale (0=not at all true; 4=completely completely true). The Flesch-Kincaid
grade level readability index is an index that ranges from 1.0 (able to be read by someone in 1st
grade) to 50.0 (unreadable). The readability of the 108 administered items was 5.8.
Subscale Convergent Validity Measures
The Parent Locus of Control Scale (PLOC) is a 60-item self-report measure of parent
attributions. Items form five factor analytically derived subscales: parental efficacy, parental
responsibility, child control of parents' life, parental belief in fate/chance, and parental control of
child's behavior (Campis et al., 1986). Items were rated on a 5-point Likert Scale from strongly
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disagree (1) to strongly agree (5). For parsimony, the five items with the highest factor loading
from each subscale were administered. Internal consistency (Chronbach’s α) for the five
subscales in previous studies ranged from .62 - .79. In the present study, the internal consistency
for three of the five subscales ranged from .65 to .73. The parental responsibility subscale had an
alpha of .50 and the parent belief in fate/chance had an alpha of .51. A confirmatory factor
analysis of data from the present study demonstrated that the five factors were a reasonable but
not ideal fit to the data [Satorra-Bentler Chi-Square = 753.76, df = 265; NFI = .701; NNFI =
.751; CFI = .78; IFI = .783; RMSEA = .062; 90% CI of RMSEA = .057-.067]. Scores were
computed the averaging parents’ responses on each subscale.
The Brief Child and Family Phone Interview (BCFPI) (Cunningham et al., 2000) is a
standardized telephone interview of problem severity that is based on the Ontario Child Health
Study scales - Revised version (OCHS-R) (Boyle et al., 1993). It is the mandated intake measure
used by all children’s mental health centres in Ontario. Parents rated 81 behaviors as ‘never’,
‘sometimes’, or ‘often’ true of their child. The present study used two of composite scales, which
were based on six factor analytically derived subscales: (a) externalizing (i.e., regulation of
attention and activity; cooperation; conduct), (b) internalizing (i.e., separation from parents,
managing anxiety and managing mood), and a subscale measuring school participation and
achievement. In addition, the externalizing and internalizing subscales were summed to provide a
variable representing the overall severity of the child’s problem. Norms and reliability were
derived from community and clinic data from the OCHS. Internal consistency (α) for six of the
seven BCFPI subscales in the community sample ranged from .75 to .86 (Cunningham et al.,
2000). T-scores were computed using the age- and sex-based norms from the community
sample.
Treatment Acceptability. Five treatment vignettes were created for this study. The
vignettes proposed five treatment scenarios: (1) individual child treatment, (2) individual parent
treatment, (3) treatment involving the child and the parent together, (4) treatment from the
child’s school and (5) medication. For each vignette parents rated (a) the acceptability of the
treatment (4 items), (b) their intention to attend treatment (1 item) and (c) perceived treatment
effectiveness (1 item). The four treatment acceptance items were selected based on the highest
factor loading of the six original items on the acceptability subscale of the Treatment Evaluation
Inventory – Short Form (TEI-SF) (Kelley, Heffer, Gresham, & Elliott, 1989; Finn & Sladeczek,
2001). The intention to attend treatment and the treatment effectiveness items were created for
this study. Parents rated the items on a five point Likert scale (1=attend no sessions, 5=attend all
sessions; 1=problem was not at all improved, 5=problem was completely improved). Scores
were computed by averaging parents’ response across the six items. Chronbach’s alpha for the
six items ranged from .91 to .96 across the treatment scenarios. The vignettes and questions were
pilot tested on 17 parents to ensure clarity and content validity.
Complexity Convergent Validity Measures
Treatment History. A questionnaire asking parents about the different places from which
they had received treatment in the past for their child’s emotional or behavioral problem was
utilized (Reid et al., 2008). Parents were asked to report any treatment received from the
medical (e.g., family physician, pediatrician, public health nurse), mental health (e.g., private
psychologist, social worker or counselor) or education (e.g., school) sectors. Parents were then
asked if they had received treatment from specific mental health agencies in their respective
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communities (Reid, Tobon, & Shanley, 2008). The number of places from which parents had
received treatment was summed.
The Complexity subscale from the Jackson Personality Inventory- Revised (JPI-R)
(Jackson, 1984) was used. It has 20 self-report items, rated as either true or false, that measure an
individual’s ability to think about life issues from multiple, complex and challenging
perspectives. Chronbach’s alpha for this subscale was .62 in the present sample. Scores were
computed by summing parents’ responses to subscale items.
Discriminant validity measures
Social desirability. The self-deceptive enhancement subscale (20 items) from the
Balanced Inventory of Desirable Responding (BIDR) was used to measure social desirability
(Paulhus, 1991). Items were rated on a 7-point Likert scale from totally disagree (1) to totally
agree (7) (Stober, Dette, & Musch, 2002). Chronbach’s alpha for this subscale was .68 in the
present sample. Scores were computed by summing parents’ responses to subscale items.
Aesthetic Responding: The Aesthetic Responding subscale from the Jackson Personality
Inventory (JPI) was chosen as a measure of discriminant validity. Parents rated 10 items on a 5point Likert scale from 1=strongly disagree to 5=strongly agree. Chronbach’s alpha for this
subscale was .75 in the present sample. Scores were computed by summing parents’ responses to
subscale items.
Data Analyses
Missing Values. Participants were telephoned and asked for their response on missing
items. Each item on the cause questionnaire had less than 1% of responses missing. Across all
items on all questionnaires, less than 0.001% of data were missing. Mean substitution within
subscales was used to impute missing data.
Item-level analyses. Corrected item-total correlations were calculated using the 12
proposed factors. Deleting items involved an iterative process whereby poor items were deleted
and corrected item-total correlations were re-calculated. The decision to drop an item was based
on: (a) frequency of endorsement (i.e., endorsed less than 5% of the time or more than 95% of
the time) (Jackson, 1970), (b) high correlations (r > .50) with the self-deceptive enhancement
subscale (Jackson, 1970), (c) low corrected item-total correlations (i.e., < .30) (Nunnally, 1978),
(d) having a correlation with one of the other 11 subscales that was greater than with the item’s
own subscale (Spector, 1992), and (e) low item efficiency index1 (Neill, 1976; Jackson, 1984).
The item efficiency index was only used in the final stage of item deletion, once the poorest
items had already been deleted (Gati, 1981). This item reduction process involved six iterations.
Careful consideration was given to item content during this process in addition to the above
statistical criteria. If the final corrected item-total correlation was somewhat low but the content
of the item was deemed to be important to the subscale definition, the item was retained
(Spector, 1992); three of final items were retained for this reason. No less than three and no more
than six items were retained for any subscale. The resulting final version of the Cause
Questionnaire was 60 items.
Confirmatory factor analysis. Confirmatory factor analysis using maximum likelihood
estimation (Hu & Bentler, 1995) in EQS 6.1 (Bentler & Wu, 2006) was calculated. The 12
1
The item efficiency index considers the corrected item total correlation and the corrected item correlations with
all other irrelevant scales. It is calculated by computing the square root of the difference between an item’s squared
correlation with its’ own subscale and the average of its’ squared correlations from all irrelevant subscales
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proposed factors were allowed to correlate, as such correlations were considered theoretically
meaningful. Due to moderate kurtosis in the data, the Satorra and Bentler (1988) Chi-Square (χ2)
statistic was reported along with the robust standard errors and goodness-of-fit indices. The
following robust goodness-of-fit indices were used: the Normed Fit Index (NFI), Non-Normed
Fit Index (NNFI), Comparative Fit Index (CFI), Bolen’s Fit Index (IFI), the Root Mean Square
Error (RMSEA), and the RMSEA confidence intervals. Recommended criteria for evaluating
these goodness of fit indices include: NNFI and NFI > .9; CFI >.9 and RMSEA < .1 (Bentler &
Bonett, 1980; Hu et al., 1995; MacCallum, Browne, & Sugawara, 1996).
Subscale correlations, reliability and descriptive statistics. Bivariate correlations
between subscales were calculated. Chronbach’s alpha was used as a measure of internal
consistency for each subscale. Descriptive statistics for each subscale, including the mean,
standard deviation, minimum and maximum scores were calculated. Consistent with the way in
which parents were asked about the cause of their child’s problem, the endorsement of each
subscale was presented according to the four main child problem categories (attention, behavior,
mood, and social problems). Parents who endorsed the fifth “other” category (n = 9), were not
included in this analysis.
Convergent and discriminant validity. Convergent and discriminant validity predictions
were calculated by correlating subscale scores and complexity scores with the scores from
measures outlined above. The subscale score for the Cause Questionnaire was calculated by
averaging parents’ responses to the items within that subscale. The complexity score for the
Cause Questionnaire was calculated by summing the endorsed subscales. A subscale was
considered endorsed if parents’ average endorsement was greater than 1 (on the scale from 0 to
4).
Results
Sample Characteristics.
Children of parents who participated in the study were 4- to 15-years-old (M = 9.4; SD =
2.7); 68% were male. Parents were 21- to 63-years-old (M = 37.4, SD =7.0); 92% were mothers,
5% (n=25) were fathers, 2.5% (n=12) were female legal guardian relatives, and 1 parent was a
male legal guardian relative. Sixty percent of parents were married or in a common-law
relationship. The majority of parents (92%) self-identified as Caucasian, 3% as Native, 2% as
Black, 1% as Chinese, and 2% as another ethnic background. The mean annual family income
was CA $30,000 - $40,000, which is comparable to the Ontario average of $35,185 (Statistics
Canada, 2002). Fifteen percent of parents did not have a high school diploma, 27% had a high
school diploma, 46% had a trade school or college diploma, and 12% had a university degree.
On average, children had clinically significant externalizing problems (M =70.2;
SD=13.7; range=35–108) and moderate internalizing problems (M =64.8; SD=14.7; range=37–
107). A third of children (33.5%) were above clinical cut-off (T > 70) for externalizing problems
alone; 14.4% had internalizing problems alone, and 20.3% had both externalizing and
internalizing problems. The children’s main problem as identified by parents was as follows:,
42% behavior or conduct, 28% attention, concentration or impulsivity, 22% mood, 6% social,
and 2% another problem (e.g., sexualized behavior, psychosis.
Psychometric properties of the Cause Questionnaire
Item-level analyses. Item level analyses indicated that each item of the cause
questionnaire meaningfully contributed to its’ intended subscale in that all items correlated more
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highly with their own subscale than with the social desirability subscale, and, with the exception
of one item from the stressful life events subscale, all items correlated more highly with their
own subscale than with other Cause Questionnaire subscales (see Appendix 1). The Item
Efficiency Index for all items was strong (M=.51; SD=.13). All items were endorsed by at least
10% of the sample and no item correlated more than 0.23 with social desirability.
Confirmatory factor analysis. The Satorra-Bentler χ2 was 3145.7 (df = 1644, p< .01).
Robust goodness-of-fit indices were: NFI = .71, NNFI = .82, CFI = .83, IFI = .84, and RMSEA =
.044; 95% CI = .042 - .046. The unstandardized parameter estimates were all positive and
statistically significant; the average standardized factor loading was 0.63 (see Table 5). Overall,
the results indicated a fair and reasonable, but not ideal fit to the data (Bentler et al., 1980; Hu et
al., 1995; MacCallum et al., 1996).
Subscale correlations, reliability and descriptive statistics. Bivariate correlations
between subscales are presented in Table 6 along with Chronbach’s alpha and descriptive
statistics for each subscale. Internal consistency was good, above .70, for nine of the 12
subscales (Nunnally, 1978). The Physical, Emotion Regulation, and Spiritual subscales had
lower internal consistencies (ranging from .58 to .65). Overall, subscale means were low, ranging
from .31 to 2.16 on a scale from 0 to 4. Standard deviations for subscales demonstrate
reasonable variability ranging from 0.5 to 1.18, indicating that despite the low values of some
subscale means, responses were still varied. Minimum and maximum values for subscale scores
confirm this variability, ranging from 0 to 2.67 on the physical subscale, 0 to 3.17 on the
community subscale, 0 to 3.83 on the parent-self subscale, and 0 to 4 on the remaining nine
subscales. The Emotion Dysregulation subscale was the most endorsed subscale (M=2.16),
followed by the Biological subscale (M=1.43) and the Motivation subscale (M=1.40). Figure 1
presents the endorsement of subscales by the child’s main problem.
Convergent validity for the subscale scores
A priori predictions for convergent validity hypotheses for subscale scores were
supported (see Table 7). The strength of these correlations ranged from small to medium
(Cohen, 1992); the median absolute correlation was .26.
Convergent validity for the complexity score
The average number of subscales endorsed by parents was 5.5 (SD=2.6, range= 0 – 12).
Only 4% of parents endorsed a single subscale as causing their child’s problem. Endorsing
multiple causes was significantly correlated with the number of treatments received during the
previous year (r = .19, p < .01) and the overall severity of the child’s mental health problem (r =
.44, p < .01). Endorsement of multiple causes did not significantly correlate with complexity of
thought (r = 0.01).
Discriminant validity
Discriminant validity analyses demonstrated that no subscale significantly correlated with
the aesthetic appreciation subscale; only one subscale (the parent-self subscale) correlated with
self-deceptive enhancement subscale (r = -.27, p < .01), indicating that the less parents endorsed
items attributing cause to themselves, the more they endorsed socially desirable items (See Table
7).
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Conclusions and Recommendations
This paper presented development of a new questionnaire that measures parents’
perceptions about the cause of their child’s mental health problem with suitable reliability and
validity. The questionnaire was developed using Jackson’s (1970) sequential strategy for scale
development, which emphasized the importance of psychological theory as well as empirical
validation in a questionnaires development. Results confirmed 12 factor analytically derived
subscales representing mutually exclusive causal categories. There are no definitive rules for
deciding when CFA indices are acceptably (Goffin, 2007). Some rules of thumb for goodness of
fit indices exist (i.e., NNFI and NFI > .9; CFI >.9; RMSEA < .1) (Bentler et al., 1980; Hu et al.,
1995; MacCallum et al., 1996); however, studies with a high degree of power also have a high
probability of model rejection. In fact, MacCallum, Browne and Sugawara (1996) calculated
that with a large degrees of freedom and sample sizes between 400 and 500, as is the case in the
present sample, there is nearly a 100% probability that the CFA analysis will reject the proposed
model. Therefore, the lack of very high model fit indices in the present sample may reflect the
combination of fairly large sample size and a model with 12 subscales and 60 items (Hoelter,
1983; Hinkin, 1995; Guadagnoli & Velicer, 1988).
The corrected item-total correlations reveal that each item meaningfully contributed to its
own subscale more so than to other cause questionnaire subscales, demonstrating additional
construct validity. The internal consistencies for the 12 subscales were good; although three
subscales had lower internal consistencies (i.e., below .7). Two factors that likely account for
this are: a) the small number of items on the emotion dysregulation and spiritual subscales, and
b) the breadth of content covered in the six items on the physical subscale may have resulted in
lower item interrelatedness (Schmitt, 1996).
Subscale means were low relative to the possible range of 0 to 4. This is not altogether
surprising given the nature of some of the items. For example, in the trauma subscale, we would
not expect parents to endorse trauma as a cause for their child’s problem if their child had never
experienced any trauma. Therefore, endorsement of a particular item can be dependent on its’
base rate in the population. However, all items on the Cause Questionnaire were endorsed by at
least ten percent of the sample. Upon closer examination of the data, the low average
endorsement of subscales resulted from averaging the few parents who fully endorsed items on
that subscale and the parents who did not endorse the items on that subscale at all. Excluding
important causal items from this measure (e.g., such as trauma) because of low base rate would
limit the questionnaires ability to describe these parents’ perception of cause.
Convergent validity of subscale scores
The hypothesized theoretical relationships with previously established measures provide
support for the convergent validity of the measure. For example, when parents’ experienced less
parenting efficacy less parental control of the child’s behavior, or more child control over the
behavior, they were more likely to view the problem as being caused by their child’s motivation.
Parents who assumed more responsibility for their child’s problem were more likely to assume
responsibility for causing it. Parents who were more likely to believe in fate or chance, were
more likely to view spiritual factors as causing their child’s problem. Overall, there was a
medium relationship [i.e., r =.30 to .50, see (Cohen, 1992)] between the severity of specific
problems (internalizing, externalizing, school participation and achievement) and the type of
causes endorsed, demonstrating that the causes endorsed are related to the presenting problem.
Medium sized correlations are ideal in that they demonstrate convergent validity, but also
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demonstrate that sufficiently different constructs are being measured; if cause and problem type
were identical constructs, correlations would be much higher (Cohen, 1992).
The treatment acceptability / engagement measure also demonstrated the predicted
relationships with causal categories. The more parents perceived medication as acceptable, the
more they viewed biology as a cause (r=.44). This confirms previous results from Freeman and
Johnston (Freeman et al., 2001) who likewise found a relationship between perceptions of
biological causes and acceptability of medication as a treatment. The remaining correlations
between treatment acceptability and cause subscales ranged from .11 to .21, which demonstrated
small, but still significant relationships between parents’ perception of cause and their intention
to participate in certain treatments.
Convergent validity for complexity score
The complexity of parents’ perceptions about child mental health problems was
significantly related to the severity of the problem and the number of treatments received for the
child’s problem. General complexity of thought about life issues was not significantly related
endorsing multiple causes, which indicates that endorsing multiple causes was not a function of
“thinking complexly” but rather a function of understanding childhood psychopathology. In
other words, the more severe a child’s problem is, the more causes the parents perceive as
responsible for the problem. It is quite probable that a single, isolated behavior have only one
cause, however as a problem intensifies, parents may be more likely to consider multiple
sources. Similarly, previous treatment likely encourages parents to consider multiple sources.
Developmental psychopathology’s perspective that multiple causes interact over time to result in
their child’s mental health problem is adopted by many professionals treating psychological
problems. Exposure to this framework during treatment likely increases parents’ agreement with
this principle.
Discriminant validity
The lack of a relationship with theoretically dissimilar measures, such as the aesthetic
appreciation subscale and self-deceptive enhancement subscales demonstrates discriminant
validity. The one subscale slightly subject to a social desirability bias was the parent-self
subscale. Thus, parents who were engaging in impression management were less likely to see
themselves as responsible (r = -.27). The correlation between the parent-self subscale and the
self-deceptive enhancement subscale is not altogether surprising given that when parents endorse
the parent-self subscale of the cause questionnaire, they are in essence, accepting blame for their
child’s mental health problem. Blaming oneself for a problem is not generally associated with
positive impression management.
Limitations
Researchers should be cautious when relying on reliability and validity results that were
collected on the sample that was used to create scale modifications (Cureton, 1978). The present
study utilized the same sample to determine appropriate items for the Cause Questionnaire and to
examine reliability and validity. As in any scale development process, this questionnaire would
benefit from replication and adaptation based on the results from future research.
The current study used a measure of treatment acceptability and engagement that was
based on an individual’s intention to accept or engage in treatment. Although behavioral
intentions predict future behaviours, the relationship is not perfect. Future longitudinal studies
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examining the impact of perceptions of cause on treatment acceptability and engagement would
be beneficial.
Implications
Parents who do not find treatments acceptable may refuse them. In fact, studies have
found that 8 to 25 percent of parents philosophically disagree with treatment approaches (Reid et
al., 2008; Shanley et al., 2008c) and perceived irrelevance of treatment is one of the largest
barriers to completing treatment (Kazdin, Holland, & Crowley, 1997). In addition, parents who
do not engage in treatment often drop-out. Drop-out rates for child treatments range from 28% to
75% (Gould, Shaffer, & Kaplan, 1985; Shuman & Shapiro, 2002; Prinz & Miller, 1996).
Variables known to increase the risk of treatment dropout are low socio-economic status,
minority racial status, younger maternal age, single parent status, more life events, higher
perceived stress, parent psychopathology, higher number of child symptoms, and lower level of
child intelligence (Kazdin, 1996). Yet, these variables do not account for all families that drop
out of treatment. Furthermore, many of these factors that predict treatment dropout cannot be
changed prior to the onset of treatment (i.e., race will not change prior to treatment). Parents’
perception about the cause of their child’s problem is one factor that likely affects treatment
engagement and could be addressed or altered prior to treatment.
Parents’ perceptions of cause correlated with their ratings of acceptability of common
treatment options, demonstrating that parents’ perceptions about the cause of their child’s mental
health problem can inform our understanding of which treatments parents view as acceptable.
Practitioners who attend to parents’ perceptions can then have the option of either matching the
treatment regimen to these perceptions or altering parents’ perceptions to match the requirements
of the treatment. Either way, such a patient-centred approach can enhance the therapeutic
alliance, which has been demonstrated to improve treatment outcome (Al-Darmaki & Kivilghan,
1993).
The average parent perceives five causal categories as responsible for their child’s mental
health problem. This corroborates Shanley et al.’s (2008a) conclusion that parents have a multidimensional view about the cause of their child’s problem. Although some parents may endorse
a simple causal model (4% endorsed only 1 of the 12 factors as causing their child’s problems),
the majority perceived multiple factors as causing their child’s problem. Future research could
test if certain subgroups of parents share particular views about cause (i.e., parents with no
previous treatment, parents of children with more severe problems, parents of children with
different types of problems), and how differing perceptions of cause influence the treatment
process (i.e., problem recognition, help-seeking, treatment acceptance, and treatment
engagement). Additional questions might include, Do parents’ perceptions of cause differ from
professionals’ perceptions? Do mothers’ perceptions of cause differ from fathers’ perceptions?
How do these differences impact the treatment process?
This questionnaire demonstrates that the current methods of measuring cause do not
capture the breadth of causes that parents perceive. It is the only questionnaire that allows for the
exploration of multiple causes within parents’ perceptions and it provides a solid foundation for
future research to examine the influence of cause on the treatment process.
Parents’ Perceptions of Child Mental Health Problems: CoE Final Report
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Knowledge Exchange and Transfer Plan
Knowledge Exchange activities accomplished to date
Presentations
Shanley, D.C. & Reid, G.J. (2007, January).Parents’ Perceptions of Child Mental Health
Problems: Development of a Parent-Report Measure. Presented to the Patient-Centered
Care Research Unit, Faculty of Health Sciences, McMaster University, Hamilton,
Ontario.
Shanley, D.C, Reid, G.J, Goffin, R., Brown, J.B., Evans, B., Stewart, S., Wolfe, V. (2006,
November). Parents’ Conceptualization of Child Mental Health Problems: Development
of a Self-Report Measure. Presented at the Research and Evaluation Day: Child and
Youth Mental Health in the South West Region, hosted by The Provincial Centre for
Excellence in Child and Youth Mental Health and the Ontario Ministry of Children and
Youth Services, London, Ontario
Shanley, D.C. & Reid, G.J. (2006, February). What Parents Perceive to be the Cause of their
Child’s Mental Health Problem: Development of a Preliminary Questionnaire. Poster
presented at The 19th Annual Research Conference: A System of Care for Children’s
Mental Health: Expanding the research base, Tampa, Florida.
Further plans regarding Knowledge Exchange activities
A copy of the study report will be distributed to the CMHC’s involved. We will also present
these findings at national conferences and manuscripts will be submitted for peer-reviewed
publications.
Presentations
Shanley, D.C. & Reid, G.J. (2008, June). Parents’ Perceptions of Child Mental Health Problems:
Development of a Parent-Report Measure. Poster presented at the Canadian
Psychological Association, Halifax, Nova Scotia.
Manuscripts in preparation
Shanley, D. C. & Reid, G. J. (2008a). Children's Mental Health Problems: Reviewing theoretical
frameworks that explain why some parents don't agree with mental health treatments.
Shanley, D. C., Brown, J. B., Reid, G. J., & Paquette-Warren, J. (2008b). Parents' Perspectives
on Child Mental Health Problems.
Shanley, D.C. & Reid, G.J. (2008c). Parents’ Perceptions about the Cause of their Child’s
Mental Health Problem: Development of a Parent-Report Measure.
Shanley, D.C. & Reid, G.J. (2008d). Parents’ Representation of their Child’s Mental Health
Problems: Applying the Self-Regulation Model to Children’s Mental Health Problems
Parents’ Perceptions of Child Mental Health Problems: CoE Final Report
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Table 1: Causes of Child Mental Health Problems: Parents’ Perspectives
Child
Family
Adjustment Difficutly in Family
Problem caused by difficulty adjusting to
family change
Examples:
• moving / placed in foster care
• change in caregiver
• change in daily routine
• birth/death of family members
• parental separation or divorce
Community
Adjustment Difficulty in School
Problem caused by difficulty adjusting to
school changes
Examples:
• starting school
• changing grades or schools
• disliking school or teacher
Child Skill Deficits
Problem caused by deficits in daily living skills
Examples:
• lack of coping skills
• lack of emotion regulation
• lack of problem solving skills
• lack of self-control
• lack of social skills
Parent
Problem caused by something internal to the
parent
Examples:
• mental or physical illness of the parent
• stress in the parents’ life, including
financial or job related stress
Teacher / Staff
Problem caused by a teacher, principal or
other school staff
Examples:
• teacher gives too much attention
to bad behavior
• teacher lacks knowledge on how
to deal with the problem
• school not working with parent
Learning/Comprehension
Problem caused by difficulty learning new information
or comprehending the age appropriate school
curriculum
Examples:
• difficulty understanding specific subjects
• difficulty completing homework
Parenting
Problem caused by parenting skills, deficits,
or conflicting parenting styles
Examples:
• discipline style (too strict, too passive)
• lack of support of child
Peers
Problem caused by peers
Examples:
• bullying
• negative influence from peers
• child does not fit in with peers
Genetics/Hereditary
Problem caused by a biological predisposition
Sibling
Problem caused by a sibling
Neighbourhood
Problem is caused by something within
Child Characteristics
Problem caused by characteristics internal to the child
Examples:
• feelings (e.g., guilt, frustration, anger,
boredom)
• personality traits (e.g., stubborn, impulsive,
manipulative, overly sensitive)
• physiological states (e.g., tiredness)
• self-esteem (too high or low)
Parents’ Perceptions of Child Mental Health Problems: CoE Final Report
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Examples:
• chemical imbalance
• genetics
• personality trait clearly identified as inherited
from a family member
Examples:
• learned behavior from the sibling
• sibling rivalry
• a lack of siblings (only child)
Disease/Disability
Problem caused by the presence of a disease or
disability
Examples:
• physical disease or disability
• learning disability
• comorbid mental health disorder (e.g., ADHD,
anxiety,depression)
Prenatal
Problem caused by something that occurred during the
mother’s pregnancy
Examples:
• prenatal stress
• drug use
• car accident
Early Childhood Attachment
Problem caused by a significant separation from the
primary caregiver at an early age
Examples:
• separation from mom perceived as negatively
affecting the bond or attachment with mom
Development
Problem caused by a developmental delay or a
developmental stage
Examples:
• speech, language, or motor delay
• puberty
Trauma
Problem caused by some form of abuse
Examples:
• physical, emotional, or sexual
• witnessing family violence
• experiencing a traumatic event (e.g.,
custody court proceedings)
• neglect
Parents’ Perceptions of Child Mental Health Problems: CoE Final Report
the surrounding community
Examples:
• lack of extra-curricular activities
• lack of good role models
• living in a bad neighbourhood
• discrimination
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Figure 1: Causal Models for Parents’ Perceptions
Diagrams demonstrate four ways in which parents integrated the presence of multiple causes.
Shaded boxes represent unique, unrelated causes. Causes in like shaded boxes represent linearly
dependent (or related) causes. Overlapping boxes represent the collective impact of multiple
causes.
Linear
Equifinality
P
P
Cause
Cause
Cause
Cause
Cumulative
P
Cause
Cause
Cause
P
Cause
Cause
Cause
Cause
Cause
Complex
Cause
Cause
P = Problem
Parents’ Perceptions of Child Mental Health Problems: CoE Final Report
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Figure 1. Average Endorsement of Subscales by Main Problem Type.
2.5
Average
Endorsement
2
1.5
Attention
Behavior
Mood
Social
1
0.5
Community
Parent-Other
Parent-Self
Spiritual
Trauma
Stress
Social
Cognitive
Emotion
Motivation
Physical
Biological
0
Subscale
Figure Caption: This figure presents the average endorsement of each Cause Questionnaire subscale for parents of children with
attention, behaviour, mood, or social problems. An average endorsement of 0 indicates that parents endorsed all items on that
subscale as “not at all true”; an average endorsement of 4 indicates that parents endorsed all items on that subscale as “completely
true”.
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Table 2. Definitions of Causal Dimensions
Dimension
Biological (Bio)
Definition
Developmental changes, genetic / hereditary, neurological /
chemical, or hormonal influences caused the child’s problem
Physical & Reactions to
The child’s physical health (from prenatal to present), a medical
Physical Environment (Phy) problem, or factors in the physical environment that influence the
child’s health (e.g., diet, allergies, pollution) caused the problem.
Motivation (Mot)
The child’s motivation, attitudes, beliefs, or effort caused the
problem.
Emotion Dysregulation
(Emo)
Emotional reactions to life, problems regulating emotions, or
difficulty controlling/expressing emotions caused the problem.
Cognitive/Academic (Cog)
The child’s intelligence, ability to learn or problem-solve caused
the problem.
Interpersonal/Social (Soc)
The child’s relationship (or lack of relationship) with age-related
peers, ability to interact with age-related peers, or modelling after
age-related peers caused the problem.
Stressful Life Events (Sle)
Difficulty adjusting to, or coping with, any major life changes
caused the problem (excluding traumatic events).
Trauma (Tra)
Abuse or a traumatic experience caused the problem. This would
include physical, sexual, verbal/emotional abuse, witnessing abuse
or another traumatic experience.
Spiritual (Spi)
Any form of spirituality including religion, beliefs, faith, or luck
caused the child’s problems.
The personal, social, or financial history of the person answering
the questionnaire or parenting practices of the person answering
the questionnaire caused the child’s problem.
Parent (Self) (PaS)
Parent (Other parent) (PaO)
The personal, social, or financial history of the child’s other parent
or the parenting practices of the child’s other parent caused the
child’s problem.
Community (Com)
The school, neighbourhood, culture or society caused the child’s
problem.
Parents’ Perceptions of Child Mental Health Problems: CoE Final Report
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Table 3. Examples of quotes used from Shanley, Reid, Brown, Paquette-Warren (2007) to
generate items
Item: My child has this problem because…
Parallel Quote
s/he was simply born this way
“I’m wondering if he’s just born that way, he’s
always been that way”
s/he has had difficulty expressing his/her true
feelings
“I don’t think he knows how to explain how he
feels”
s/he has had difficulty adjusting to a change
“Uprooting him again from that foster home to
come to my home”
s/he has found school work too hard
“Part of it is school because he knows he’s
behind and he knows he’s not like the other
kids so I think that creates some frustration”
I have not spent enough time with my child
“I’m a single mother so I didn’t really get to
spend much time with her for three years
because [school] was really demanding a lot”
the school has disciplined my child differently
from the way I do at home
“You know she’s got to have some discipline
other than just at my house. At school she’s not
really getting disciplined.”
Note: Quotes are in response to the qualitative open-ended question: “What do you think caused
your child’s problem?”
Parents’ Perceptions of Child Mental Health Problems: CoE Final Report
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Table 4. A Priori Predictions for Construct and Discriminant Validity
Bio
Phy
Mot
Emo
Cog
Soc
SLE
Tra
Spi
PaS
PaO Com
Parent Locus of Control (PLOC)*
Lack of Parenting Efficacy
+
Parental lack of Responsibility
+
High Child control of parent’s life
+
High Parental belief in fate/chance
+
Lack of Parental control of child
+
behaviour
Child adjustment (BCFPI)
Internalizing
+
Externalizing
+
School Participation and
+
+
Achievement
Treatment Acceptability
Child
+
+
Parent
+
Family
+
School
+
+
Medication
+
Social Desirability (BIDR)
Self-Deceptive Enhancement
0
0
0
0
0
0
0
0
0
0
0
0
Aesthetic Appreciation Subscale
0
0
0
0
0
0
0
0
0
0
0
0
*= subscale titles were altered to provide clarity about the direction of the relationship
+ = small to medium positive correlation is predicted; 0= no significant correlation is predicted
Blank cells that are empty have no a priori hypothesis
PLOC=Parent Locus of Control Scale; BCFPI=Brief Child and Family Phone Interview; BIDR =Balanced Inventory of Desirable
Responding
Parents’ Perceptions of Child Mental Health Problems: CoE Final Report
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Table 5. Confirmatory Factor Analysis Results
Item Number
Unstandardized Standard Standardized
Solution
Error
Solution
Biological
1.
.871
.054
.639
2.
.773
.060
.559
6.
1.093
.046
.786
8.
1.109
.050
.788
13.
.671
.064
.466
18.
.887
.061
.628
4.
.325
.060
.298
9.
.339
.056
.430
10.
.434
.042
.725
11.
.599
.059
.654
12.
.497
.056
.618
14.
.255
.053
.332
23.
.800
.058
.611
24.
.853
.060
.597
Physical
Motivation
Parents’ Perceptions of Child Mental Health Problems: CoE Final Report
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37.
.904
.053
.653
38.
1.005
.056
.658
47.
.968
.056
.673
48.
.885
.056
.629
29.
.678
.069
.496
40.
.904
.053
.650
49.
.801
.064
.611
28.
1.076
.061
.701
44.
1.220
.052
.814
46.
.639
.060
.663
31.
1.266
.044
.873
32.
.639
.064
.488
35.
1.287
.044
.884
41.
1.144
.049
.794
42.
.745
.063
.509
43.
.543
.061
.442
Emotion Regulation
Cognitive
Social
Parents’ Perceptions of Child Mental Health Problems: CoE Final Report
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Stressful Life Events
55.
.944
.067
.695
56.
1.021
.060
.748
60.
1.100
.052
.735
61.
.611
.078
.418
67.
.848
.071
.534
52.
1.267
.061
.800
54.
1.311
.061
.826
58.
.458
.068
.488
66.
.717
.067
.612
53.
.598
.089
.630
65.
.472
.086
.566
70.
.311
.077
.503
76.
.566
.062
.604
78.
.635
.061
.637
80.
.543
.056
.653
Trauma
Spiritual
Parent (self)
Parents’ Perceptions of Child Mental Health Problems: CoE Final Report
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100.
.425
.053
.612
103.
.693
.069
.582
104.
.953
.052
.726
71.
1.198
.060
.739
72.
1.374
.045
.865
73.
1.434
.044
.856
77.
.788
.062
.590
89.
1.157
.059
.710
97.
.600
.068
.435
74.
1.132
.058
.791
75.
.261
.057
.263
81.
.611
.065
.542
83.
1.121
.055
.839
94.
.230
.049
.317
106.
.583
.057
.575
Parent (other)
Community
Parents’ Perceptions of Child Mental Health Problems: CoE Final Report
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Table 6. Correlations between subscales, subscale internal consistency, mean and standard
deviation
Factors
Bio
Biological
1.00 -
Physical
Motivation
Phy
.24 1.00
-.05
Mot
Emo
Cog
Soc
Sle
Tra
Spi
PaS
PaO Com
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
.15 1.00
-
-
-
-
-
-
-
-
-
1.00
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
Emotion
.06
.19
.45
Cognitive
.21
.24
.25
.24 1.00
Social
.14
.25
.41
.41
.39 1.00
-.05
.15
.37
.40
.13
.30 1.00
Trauma
-.12
-.01
.26
.21
.03
.11
.50 1.00
Spiritual
.24
.24
.13
.11
.13
.15
.09
.05 1.00
Parent (self)
-.02
.15
.32
.28
.06
.21
.28
.16
.13 1.00
Parent (other)
-.11
-.01
.41
.27
.06
.15
.50
.59
.02
.30 1.00
.14
.19
.29
.22
.36
.36
.20
.12
.21
.23
.20
1.00
6
6
6
3
3
6
5
4
3
6
6
6
.81
.65
.80
.61
.76
.83
.75
.77
.58
.80
.85
.73
1.43 0.40 1.40
2.16 1.09 1.30 1.21 0.84 0.31 0.61
1.28
0.70
0.99 0.50 1.00
1.01 1.11 1.03 1.04 1.04 0.59 0.72 1.18
0.73
Stressful Life
Events
Community
# of items per
subscale
Chronbach’s
alpha
Mean
Standard
Deviation
Minimum
0
0
0
0
0
0
0
0
0
0
0
0
Maximum
4 2.67
4
4
4
4
4
4
4 3.17
4
3.83
Parents’ Perceptions of Child Mental Health Problems: CoE Final Report
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Table 7. Construct and Discriminant Validity Correlations.
Bio Phy Mot Emo Cog Soc SLE Tra Spi PaS PaO Com
Parent Locus of Control (PLOC) ***
Lack of Parenting Efficacy
.32**
Parental lack of Responsibility
-.28**
High Child control of parent’s
.31**
life
High Parental belief in
.14*
fate/chance
Lack of Parental control of child
.45**
behaviour
Child Adjustment (BCFPI)
Internalizing
.31**
Externalizing
.49**
School Participation and
.24**
.37**
Achievement
Treatment Acceptability
Child
.14* .13*
Parent
.19**
Family
.11*
School
.21**
.18**
Medication
.44**
Social Desirability (BIDR)
Self Deception
-.01 -.05 -.03 -.09 .02
-.02 .04 .09 -.05 -.27** .05 .02
Aesthetic Appreciation Subscale
-.04 .03 -.06 .08
.00
-.01 .01 .09 .07 -.03 .06 -.03
*
p<.05; **
p<.01; ***
subscale titles were altered to provide clarity about the direction of the relationship
blank cells that are empty have no a priori hypothesis
PLOC=Parent Locus of Control Scale; BCFPI=Brief Child and Family Phone Interview; BIDR= Balanced Inventory of Desirable
Responding
Parents’ Perceptions of Child Mental Health Problems: CoE Final Report
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